Member/Participant Incident Report Form

Member/Participant Incident Report

Branch/Location

Specific branch where incident took place

Off Site Location

Name and Address

Injured Person Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent/Guardian Phone

Parent/Guardian

First Last

If injured person is under 18

Parent/Guardian Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Incident Date

Incident Time

Age

Type

Member

Program participant

Guest

Employee

Other

General information on incident

Describe exactly what happened

Medical Information and Response

Medical Information

Fully describe the injured party’s condition and any first aid given

Was first aid administered

Yes

by whom:

Blood-borne exposure:

Yes

To whom was exposed:

Was there further Medical Attention

Yes

Declined

If so where and by whom:

Was a parent/guardian/emergency contact notified?

Yes

Who was notified and what was the outcome?

With whom did the injured party leave the site:

Witnesses

Please list any witness and indicate a staff, participant, volunteer or youth (include age).

Witness

Include Name, Phone, Address and whether staff, participant, volunteer, or youth

Witness

Include Name, Phone, Address and whether staff, participant, volunteer, or youth

Witness

Include Name, Phone, Address and whether staff, participant, volunteer, or youth

Incident Management

Waiver Forms

Member

Program

Day pass

Other

None

Staff member filing report

Name, Title, Date

Supervisor reviewing report

Name, Title, date

Executive Director reviewing report

Name, Title, Date

Was there follow-up contact

Yes

Detail status of follow up

Date, by whom, result

Incident Details, Location and Injury

Program

In what program was the injured person participating at time of incident?

Other – please specify

Specific Location of Incident

Where did the incident happen

Other – please specify

General Activity

Other – please specify

Specific Action

Other – please specify

Source of Injury

Other – please specify

Apparent Injury

Other – please specify

Body Part

Additional Comments

Youth & Families

Swimming & Pools

Health & Wellness

Membership

Get Involved

Andover/North Andover

Lawrence

Methuen